Nurse Care Manager

Nurse Care Manager

Requirements

• Must have reliable access to high-speed internet to ensure seamless remote work communication and productivity
• Current Registered Nurse license is required
• Prior experience with electronic health records or health registries required
• Microsoft Office skills, including Excel, Word, PowerPoint, Outlook required; Experience with PowerPoint preferred

Responsibilities

• Manage patients’ specialized needs based on their individual condition(s) in collaboration with an assigned panel of physicians, advanced practice providers, and care coordination team members
• Take full ownership of patients within your panel, with an additional focus on patients with complex chronic conditions, serious illness, or advanced frailty
• Perform assessments to identify members’ needs based on their values, goals and preferences
• Develop comprehensive care management plans for each member
• Coordinate patient care delivery with Honest clinicians, network providers, contracted vendors, and community-based services
• Quickly build empathetic relationships with patients and families
• Evaluate and identify patients’ needs based on their respective values, goals, and preferences, then translate these needs into clinical needs
• Interface with primary care physicians, advanced practice providers (APP), specialists, and various disciplines on the development of case management plans/programs
• In conjunction with the physician/APP, implement care/treatment plans by coordinating access to health services across multiple providers/ disciplines
• Refer patients to internal Honest team members for care management activities as outlined by defined procedures
• Monitor care and identify cost-effective measures, including recommendations for alternative levels of care and utilization of resources
• In partnership with Honest team members, effectively coordinate patient admissions and discharges from hospitals or skilled nursing facilities via coordination with respective facility clinicians and case managers
• Build relationships across network hospitals, SNFs, home health companies, and DME vendors within the respective community
• Monitor and evaluate the effectiveness of the case management plans based on quality and cost drivers and modify as necessary
• Coordinate the interdisciplinary approach to providing continuity of care, including transfer coordination, discharge planning and obtaining all authorizations/approvals/transfers as needed for outside services for patients/families
• Act as a patient advocate and educator to assure that the patient has the knowledge to care for his/her condition and patient is educated and empowered to be responsible for participating in the plan of care
• Develop individualized patient/family education plan focused on self-management and deliver patient/family education specific to a disease state
• Engage internal resources to identify and respond to social determinants of health such as lack of transportation, stable housing, or food resources
• Participate in data collection and analysis of clinical outcomes of care and customer satisfaction standards
• Participate in the formulation and implementation and monitoring of action strategies and outcomes of care or customer service
• Ensure that accurate records are maintained of the care associated with each patient
• Actively participate in huddles, interdisciplinary team (IDT) sessions, and patient case conferences
• Commendably represents Honest to patients, their families, and the community
• Perform other related responsibilities as assigned

Preferred Qualifications

• Bachelor’s of Science in Nursing preferred
• Certified Case Manager (CCM) credential preferred
• 3+ years of clinical practice in a hospital, clinic, home care, or nursing home setting highly preferred
• Case management experience with a senior population preferred
• Disease management and/or physician office experience highly preferred